Map of life expectancy at birth from Global Education Project.

Monday, May 14, 2007

No, it won't be paradise . . .

If the U.S. should somehow, some day, end up with something resembling universal, comprehensive, single payer national health care, will all the sky be filled with rainbows and the trees filled with birds sweetly singing? Probably not. As Tony Blair heads for the ash heap of history, Polly Toynbee in the BMJ considers his legacy with respect to the National Health Service. (Link is to the gateway page, click again for the PDF. If you do read the article, I don't know what the photograph is all about -- Tony seems to be enjoying an afternoon stroll through beautiful downtown Baghdad with his buddy John McCain.)

Now, few in the U.S. actually advocate for a UK-style system. Rather, most sensible people who know what they are talking about think that a Canadian-style system is more feasible and appropriate for the U.S. As most readers undoubtedly know, Britain has fully socialized medicine, in which physicians are state employees. Canada has socialized health care insurance, but private medicine. Nevertheless, some of the problems both nations encounter are similar.

Defenders of the U.S. non-system always raise massive alarms about waits for elective surgery in the UK and Canada. This sort of rationing by inconvenience (rather than by sensible judgment about what is cost effective, which is a strength of both systems) happens because of politics. Voters always want something for nothing. They want all the goodies government can offer, but they don't want to pay taxes. Politicians pander to these contradictory demands, and so publicly financed health care can end up with some resource constraints. It is particularly compelling, therefore, that even though many people believe that both the UK and Canadian systems have been chronically underfinanced, they still manage to consitently get much better results than we do.

Anyway, as Toynbee points out, but in my view doesn't succeed in explaining very well, under the Blair government financing for the National Health Service actually increased substantially, and waiting times decreased dramatically, but the public is still unhappy with the results. From what I can extract from Toynbee's essay, a big reason is that Blair's attempts to introduce market forces into the system caused distortions, in which hospitals fattened at the expense of primary care, and public health and preventive medicine suffered. This is not surprising. As I have argued here many times, the mythical "free market" does not produce efficient outcomes in medicine, whether from the standpoint of the individual consumer, or society.

Another problem, for which Blair perhaps deserves more credit than blame, is that efforts to rationalize the system created losers as well as winner, notably in efforts to close some hospitals and hospital-based services which were superfluous. When hospitals close in the U.S., there's nobody to blame, but in a publicly financed system, it's very difficult to take anything away from people. That's why we can't seem to close military bases either.

So, if we do achieve single payer national health care, la lucha continua. It will continue to be a political struggle, forever, to maintain the system at a high level of quality. Note, as a cautionary example, how the VA medical system has had its ups and downs over the years. But that's no reason not to do it. Even with all the problems we can anticipate, it will still be vastly better than what we have now.

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